Transcription of 2015 Form 1094-C
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2015 Form 1094-C
120116 CORRECTEDForm1094-CDepartment of the Treasury internal revenue ServiceTransmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns Information about Form 1094-C and its separate instructions is at No. 1545-22512015 Part IApplicable Large Employer Member (ALE Member)1 Name of ALE Member (Employer) 2 Employer identification number (EIN)3 Street address (including room or suite no.)4 City or town5 State or province6 Country and ZIP or foreign postal code7 Name of person to contact8 Contact telephone number9 Name of Designated Government Entity (only if applicable) 10 Employer identification number (EIN)11 Street address (including room or suite no.)12 City or town13 State or province14 Country and ZIP or foreign postal code15 Name of person to contact 16 Contact telephone numberFor Official Use Only17 Reserved.
120116. CORRECTED. Form. 1094-C. Department of the Treasury Internal Revenue Service. Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns
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